A journal review by: Adrienne Holloway Erica Gaddis Nutrition Assessment and Therapy 2

1. Omega-3 fatty acid treatment of children with attention-deficit hyperactivity disorder: A randomized, double-blind, placebo-controlled study. A journal review by: Adrienne Holloway Erica Gaddis Nutrition Assessment and Therapy 2 Kelly Marrow, MS.RD Bastyr University Spring 2012

2. Journal Article • Bélanger SA, Vanasse M, Spahis S, Sylvestre MP, Lippé S, l’Heureux F, Ghadirian P, Vanasse CM, Levy E. Omega-3 fatty acid treatment of children with attention-deficit hyperactivity disorder: A randomized, double-blind, placebo-controlled study. Paediatr Child Health. 2009;14(2):89-98.

3. Clinical Scenario • DJ • 9 year old boy • Hyperactive, inattentive at school • Teacher notices periods of “day-dreaming”, unfocused, difficulty completing tasks, occasional misbehavior • Parents notice he has had greater difficulty being attentive to tasks, conversation and work at home • Recently diagnosed with ADHD, subset inattentive • Parents referred by ND, requesting alternative treatments

4. Article Search Methods • Article was found in MedLine • Primary search term “attentiondeficit hyperactive disorder” yielded 1854 results • Clinical query search term “omega-3 treatment of attentiondeficit hyperactivity disorder” yielded 66 results • Article chosen because it supported nutritional intervention study with ADHD

5. Description of Study • Study type: double-blind, one-way, crossover randomized • Took place in Montreal, Quebec • Children ages 6 yrs 11 mo to 11 yrs 11 mo • All children pre-diagnosed with ADHD regardless of subtype

6. Research Question • What was the safety and effectiveness of using an n-3 PUFA supplement versus a placebo on the fundamental symptoms of ADHD in children?

7. Importance • ADHD is the leading childhood neurological disorder in Canada with a variety of treatment methods. • Non-pharmaceutical methods are often explored to avoid pharmaceutical side effects on children, as well as accommodate parental desire to treat their children with alternative therapies.

8. Detailed Analysis • Study lasted for 16 weeks • 37 patients of which 26 completed the study • 13 group A • 13 group B • Study was divided into two phases of eight weeks each

9. Excluded from study • Mental health disorders (except characteristic comorbidity) like depression, anxiety, etc. • Medical condition requiring long-term treatment • Chronic neurologic condition • Paroxysmal disorder (epilepsy) • Allergic to sunflower oil / fish • Coagulation abnormalities • Candidates for surgery • Received anticoagulants • Only one child in a family • Excluded if used natural medicine products that increased risk of hemorrhage • Had surgery planned • Consume fish, flaxseed oil, foods enriched with n-3PUFA

10. Questionnaire • Utilized to evaluate changes in the children’s ADHD symptoms • Questionnaires completed by parents and teachers at baseline, mid point and termination of study • Conners’questionnaire • The Strengths and Weaknesses in ADHD and Normal Behaviors (SWAN) questionnaire

11. Primary Results Research Question: What was the safety and effectiveness of using an n-3 PUFA supplement versus a placebo on the fundamental symptoms of ADHD in children? • No noted adverse effects of n-3 PUFA supplementation • Did show reduction of DSM-IV symptom - inattentiveness • Significant clinical improvement of symptoms (30.7%) • No follow-up was conducted after the conclusion of the study • Some parents elected to continue with n-3 PUFA supplementation instead of traditional medication.

12. Database Review Natural Standard: • Review of review papers and clinical studies • Trend: • Open-label EFA supplementation trials improve ADHD symptoms • Randomized control trials generally unsuccessful at indicating n-3 PUFA as effective behavioral treatment

13. Database Review Up to date • Review study • Concluded that thru reviewed clinical trials and “professional experience” of authors, patients may benefit from omega-3 supplements.

14. Database Review The Cochrane Library: • One article supported n-3 PUFA supplementation works positively on ADHD children with inattentive subtype. • 75 children in study • One-way, crossover trial • Majority didn’t respond to n-3/n-6 tx • 26% responded with >25% reduction in ADHD inattentive symptoms

15. Is the case study applicable to our patient? • Yes, it is possible that n-3 PUFA supplementation will benefit DJ and reduce his symptoms of inattention. • As seen in database review may improve symptoms 25% or more. • Suggest coordination of care with primary care doctor, teacher, therapist or counselor and / or other natural medicine practitioners.

16. One Strength andOne Weakness of the Article • Strength: one-way, crossover design • Weakness: non-compliance of a few parents and teachers to complete the SWAN and Conners’ questionnaires

17. Resources • Millichap JG, Yee MM. The diet factor in attention-deficit/hyperactivity disorder. Pediatrics. 2012 Feb;129(2):330-7. • RazR, Gabis L. Essential fatty acids and attention-deficit–hyperactivity disorder: a systematic review.Dev Med Child Neurol. 2009 Aug;51(8):580-92. • Johnson M, Ostlund S, Fransson G, Kadesjö B, Gillberg C. Omega-3 / omega-6 fatty acids for attention deficits hyperactivity disorder: a randomized placebo-controlled trial in children and adolescents. J AttenDisord. 2009 Mar;12(5):394-401. • Side bar image from: http://spcsales.com/blog/uploads/ckfinder/images/Omega3s.jpg, Accessed 27 May 2012. Background design by Erica Gaddis Text and information by Adrienne Holloway and Erica Gaddis